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The role of ultraviolet-B from sun exposure on vitamin D3 and parathyroid

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 Asian J Gerontol Geriatr 2007; 2: 126–32

The role of ultraviolet-B from ORIGINAL ARTICLE

sun exposure on vitamin D3 and
parathyroid hormone level in elderly
women in Indonesia
S Setiati1 MD, PhD, M Oemardi2 MD, B Sutrisna3 MD, PhD,
Supartondo4 MD

ABSTRACT 1
Division of Geriatric, Department of
Internal Medicine, School of Medicine,
Objectives. To assess the effect of ultraviolet-B (UVB) from sun University of Indonesia, Indonesia
exposure on vitamin D3 [25(OH)D] status and parathyroid hormone 2
Division of Endocrine Metabolic,
Department of Internal Medicine, School
(PTH) concentration in elderly Indonesian women. of Medicine, University of Indonesia,
Methods. A total of 74 elderly women were randomised into the Indonesia
3
Faculty of Public Health, University of
intervention group (receiving UVB from sun exposure at 0.6 minimal Indonesia, Indonesia
erythemal dose/hour on the face and both arms 3 times a week for 6 weeks 4
Division of Geriatric, Department of
plus calcium carbonate 1000 mg per day) and a control group (receiving Internal Medicine, School of Medicine,
University of Indonesia, Indonesia
only calcium carbonate 1000 mg per day). Main outcome measures were
25(OH)D, PTH, and serum calcium levels at weeks 0 and 6.
Results. The prevalence of 25(OH)D deficiency was 35%. In the
intervention group, the mean 25(OH)D concentration increased from
59 nmol/L to 84 nmol/L, but increased only slightly in the control group.
There was no change of PTH levels in either group. In the intervention
subgroup with deficient serum levels of 25(OH)D, post-intervention
levels increased markedly, but PTH levels decreased only slightly.
Conclusion. Ultraviolet B from sun exposure for 25 minutes, 3 times a Correspondence to: Dr S Setiati, Division of
week for 6 weeks improves the vitamin D status, but not the PTH levels. Geriatric, Department of Internal Medicine,
Faculty of Medicine, University of Indonesia,
Jl. Diponegoro no.71, Jakarta 10430,
Key words: Aged; Parathyroid hormone; Sunlight; Ultraviolet rays; Indonesia. E-mail: s_setiati@plasa.com,
Vitamin D s_setiati@yahoo.com

INTRODUCTION vitamin D deficiency is related to lower muscle

Vitamin D is important for proper development
and maintenance of serum calcium levels, skeletal
integrity, vascular health, and cancer prevention.1-3
The hormonal form of vitamin D [1,25 (OH)2D3]
acts through a nuclear receptor with many functions,
including calcium and phosphate absorption in the
intestine, calcium mobilisation in bone, and calcium
reabsorption in the kidney, all of which maintain
calcium homeostasis and bone mineralisation in the
body.4-7
Vitamin D deficiency leads to secondary
hyperparathyroidism, increased bone turnover,
bone loss, and is also implicated as a cause of hip
fracture.8-12 Furthermore, in the elderly population,
strength, increased body sway and falls.13-17 Several
factors contribute to vitamin D deficiency in elderly
women, including: decreased vitamin D synthesis in
the skin, reduced metabolic activity in the liver and
kidney, diminished sun exposure, and lower vitamin
D intake.18-22
Vitamin D deficiency in the elderly population
can be treated by supplementing vitamin D (orally or
by injection) or increasing vitamin D synthesis with
ultraviolet (UV) irradiation using artificial ultraviolet-
B (UVB) or sun exposure. Most studies to date have
entailed vitamin D supplementation and artificial
UV irradiation.23-26 Only a few studies have reported
the effect of sun exposure as a means of increasing
vitamin D3 [25(OH)D].27,28 Whether UVB from

126 Asian Journal of Gerontology & Geriatrics Vol 2 No 3 December 2007


sun exposure in equatorial countries can increase
25(OH)D and decrease parathyroid hormone (PTH)
concentration among elderly women was the question
we posed. Our study population in Indonesia had
the following features: type-4 brown skin, old age,
low body mass index, and physiological changes in
many organ systems related to vitamin D synthesis.
It was reported that 7-dehydrocholesterol in the skin
was reduced due to the ageing process.19,29 Another
question to resolve was the proper extent of sun
exposure time necessary. Thus, the aim of our study
was to obtain the dosage of additional sun exposure
(in terms of intensity and duration) necessary to yield
a measurable difference in 25(OH)D and PTH levels
in elderly Indonesian women.
METHODS
Ours was a randomised clinical trial with a parallel
design, entailing additional UVB from deliberate
sun exposure as the intervention. The study was
undertaken during the wet (rainy) season (February
to March 2006) on elderly women from four
randomly selected institutionalised care units (two
were government run and two were privately run) in
two cities, Jakarta and Bekasi.
All the subjects were elderly women (≥60 years)
who fulfilled the entry criteria (not bed ridden, willing
to enter study, no liver abnormalities, kidney failure
or skin cancers, and not in receipt of phenobarbitone
or phenytoin). Data pertaining to each subject
(demographic characteristics, time and length of
sun exposure, 25(OH)D, PTH and serum calcium
levels, nutrient intake [calorie, protein, fat, calcium,
and vitamin D], height, weight, and skin type)
were collected. A UV meter (UV meter model 7.0,
Solartech, US) was used to measure UVB intensity
from sun exposure, a microtoise and a weighing scale
to measure height and weight. A mexameter was
used to obtain the melanin index (for skin type), and
food recall and food record questionnaires to collect
nutritional information. Levels of 25(OH)D and PTH
were measured by enzyme-linked immunosorbent
assay30,31 performed in an internationally standardised
(ISO 9001) clinical laboratory. As the latter two
molecules are very unstable at room temperature,
the blood samples were kept in the freezer at -20ºC
to prevent underestimation before measurement.
Vitamin D deficiency was defined as a 25(OH)D
level of <50 nmol/L. Increased PTH level was
Asian Journal of Gerontology & Geriatrics Vol 2 No 3 December 2007 127
Sun exposure on vitamin D3 and parathyroid level
defined as a level of >69 pg/mL. Before the study, all
four research assistants received training regarding
all necessary procedures as well as the study protocol.
Sample size was determined based on the confidence
interval of 95%, a study power of 90%, and assuming
an effect size of 20%. A total of 80 elderly subjects
were recruited.
The study entailed two stages. In the first stage,
the intensity of UVB from sun exposure was measured
in the randomly selected institutionalised care units
in Jakarta and Bekasi, where the study was being
carried out. Measurement of sun exposure intensity
was performed daily, every hour, from 7 am to 4 pm,
over 7 consecutive days . The minimal erythemal
dose (MED)/hour as recorded by the UV meter was
noted and a mean value was calculated. The time and
duration of each exposure were based on the exposure
intensity calculated as above. In the second stage, 20
subjects from each institutionalised care unit were
randomised to either an intervention or control group.
Those in the intervention group were trained to expose
their face and both arms to sun for specified durations
at specified times, as defined in the first stage. The
intervention was carried out 3 times a week for 6
weeks. Subjects were advised to carry out recreational
activities and wear sunglasses during each exposure,
without application of sunscreen to their face and
arms. Subjects in the control group were trained to
carry out corresponding activities indoors.
Subjects in both groups were given calcium
carbonate 2 x 500 mg per day during 6 weeks of
observation. They were questioned in terms of
outdoor activities, as well as about the frequency and
duration of such activities before entering the study.
Data on each subject’s nutrient intake were collected
before and during the study, based on 24-hour food
recall and food weighing (performed by dietitians).
Serum 25(OH)D, PTH, and calcium levels were
measured before and 6 weeks after sun exposure.
Data were analysed using Stata (version 8.0).
Mean values for MED/hour in the first stage was
calculated to determine the exact dose for sun
exposure. t-Test for paired samples were used
to compare the difference of 25(OH)D and PTH
levels before and after the intervention. t-Tests for
independent samples were used to compare the
difference of 25(OH)D and PTH levels after 6 weeks
in the exposed (intervention) and unexposed groups.
Setiati et al

Table 1
Mean minimal erythemal dose (MED) per hour at the selected institutionalised care
units

Time Mean MED/hour

West Jakarta North Jakarta South Jakarta Bekasi
07.00 0.1 0.1 0.2 0.4
08.00 0.2 0.4 0.4 0.5
09.00 0.6 0.7 0.7 0.6
10.00 0.8 1.2 1.1 0.8
11.00 1.3 1.4 1.8 1.2
12.00 1.1 1.7 2.3 1.6
13.00 0.8 1.3 2.1 1.8
14.00 0.6 0.9 1.3 1.2
15.00 0.2 0.6 0.6 0.4
16.00 0.1 0.5 0.3 0.4

Any p values of <0.05 denoted statistical significance (p>0.05) or the frequency of being outdoors and
using two-tailed tests. the duration of sun exposure (p>0.05). Before
intervention, 26 (35%) of the subjects had 25(OH)D
RESULTS deficiency and/or an elevated PTH concentration.

The lowest intensity of sun exposure was obtained at
7 am. The intensity increased rapidly until 11 am, after
which it stabilised somewhat but reached maximum
at 2 pm (Table 1). According to Holick,4 the simplest
way to obtain vitamin D from sun exposure was by
exposing face, arms, and hands for a period equal to
25% of the time that it would take to cause 1 MED. In
this stud­y, the highest intensity (more or less 2 MED/
hour) occurred at 11 am to 1 pm. Thus it took only ¼
x 60 minutes/2 = 7.5 minutes to increase 25(OH)D
concentration. It transpired that high UVB intensity
(heat of sunlight) at 11 am to 1 pm caused patients
inconvenience and decreased their compliance. The
preferred time for sun exposure was at 9 am, when
the UVB intensity was 0.6 MED/hour, meaning that it
took 25 minutes (¼ x 1 MED/0.6 MED x 60 minutes)
for each exposure. All subjects in the intervention
group then received 25 minutes for each exposure, 3
times a week for 6 weeks.
The 80 subjects recruited consisted of 42 in the
intervention group and 38 controls. Six from the
former group were excluded from the analysis due
to incomplete sun exposure. A total of 74 subjects
completed the study. Most (77%) of the subjects
were aged 60 to 75 years and the rest were 76 to
90 years old. The characteristics of the subjects in
the two groups are shown in Table 2. There were
no statistically significant differences in this regard
After 6 weeks of sun exposure, the mean
25(OH)D concentration increased significantly
(p<0.001). Mean values and percentage differences
of 25(OH)D concentration before and after this
period were significantly higher in the intervention
group than in the controls (p=0.01). The mean
25(OH)D and PTH concentrations before and after 6
weeks of sun exposure are shown in Table 3. Before
commencement, the mean 25(OH)D concentration
in the intervention group was lower in older than
younger subjects; the mean percentage change was
also greater in those who were older.
For further analysis, subjects were divided into
those with normal and deficient 25(OH)D concen-
trations. Table 4 shows that in the intervention group,
25(OH)D concentration increased significantly, and
more so in the deficient than normal group (77% vs
32%). In the deficient group, the PTH level decreased
1% after sun exposure but in the normal group it
increased 11%. There was no statistically significant
difference between those two groups (p=0.34).
Serum calcium levels increased significantly both in
the deficient and normal groups (both p<0.001). In
the control group, subjects with normal 25(OH)D
concentrations had an increase in their mean
25(OH)D concentration after 6 weeks. In the deficient
group, mean 25(OH)D concentration increased but
not to a statistically significant extent, and mean

128 Asian Journal of Gerontology & Geriatrics Vol 2 No 3 December 2007

 Sun exposure on vitamin D3 and parathyroid level

Table 2
Demographic and lifestyle characteristics of subjects in the intervention and control groups before
treatment period*

Characteristic Intervention group (n=36) Control group (n=38) p Value

Age (years) 71±6 72±8 0.69†
Body mass index (kg/m ) 2
2±4 22±4 0.67†
Calcium ion (mmol/L) 1.09±0.03 1.10±0.04 0.12†
Vitamin D3: 25(OH)D (nmol/L) 59.1±20.4 64.8±21.5 0.25†
Parathyroid hormone (pg/mL) 62.9±2.6 58.5±2.1 0.43†
Calorie intake (Kcal) 1469±403 1500±399 0.74†
Protein intake (g) 34±9 35±9 0.69†
Calcium intake (mg) 254±8 242±10 0.59†
Vitamin D intake (µg) 20±8 20±15 0.79†
Outdoor frequency
Never 1 (3%) 5 (13%) 0.13‡
1/week 14 (39%) 19 (50%)
2-3/week 20 (56%) 12 (32%)
>3/week 1 (3%) 2 (5%)
Length of sun exposure per day (minutes)
None 1 (3%) 5 (13%) 0.19‡
<30 11 (31%) 14 (37%)
30-60 10 (28%) 11 (29%)
>60 14 (39%) 8 (21%)

* Data are shown in mean±SD or No. of patients (%)

†
Independent t-test
‡
Chi squared test

Table 3
Mean vitamin D3 [25(OH)D], parathyroid hormone (PTH), and serum calcium concentrations before
and after 6-week treatment period

Variable Week 0 Week 6 Mean change (%) p Value (dependent

t-test)
Mean (SD)
25(OH)D (nmol/L)
Intervention group (n=36) 59.1 (20.4) 84.3 (21.2) +52 <0.001
Control group (n=38) 64.8 (21.5) 71.2 (23.2) +12 <0.001
p Value (independent t-test) 0.01 <0.001
PTH (pg/mL)
Intervention group (n=36) 62.9 (2.6) 64.5 (2.5) +7 0.62
Control group (n=38) 58.5 (2.1) 62.9 (2.7) +10 0.07
p Value (independent t-test) 0.82 0.65
Serum calcium (mmol/L)
Intervention group (n=36) 1.09 (0.03) 1.19 (0.04) +9 <0.001
Control group (n=38) 1.09 (0.04) 1.28 (0.09) +17 <0.001
p Value (independent t-test) <0.001

PTH levels increased from 70 to 79 pg/mL.
DISCUSSION
Studies about the effect of UVB irradiation on
25(OH)D concentration were generally carried out in
white types-2 and -3 skin colour populations using
artificial UVB.24-26 This is the first study to explore
the effect of UVB from sun exposure on 25(OH)D
and PTH levels in elderly women with type-4 skin.

Asian Journal of Gerontology & Geriatrics Vol 2 No 3 December 2007 129

Setiati et al

Table 4
Vitamin D3 [25(OH)D], parathyroid hormone (PTH), and calcium ion concentrations after treatment
period and percentage change from pre-treatment values

Variable Week 0 Week 6 Mean change (%) p Value (dependent

t-test)
Mean (SD)
Intervention group
25(OH)D (nmol/L)
25(OH)D normal (n=20) 74.9 (12.8) 96.6 (19.2) +32 <0.001
25(OH)D deficient (n=16) 39.4 (4.6) 68.8 (11.2) +77 <0.001
p Value (independent t-test) <0.001 <0.001
PTH (pg/mL)
25(OH)D normal (n=20) 53.3 (1.7) 57.3(1.7) +11 0.22
25(OH)D deficient (n=16) 76.1 (2.7) 74.1 (2.9) -1 0.74
p Value (independent t-test) 0.34 0.34
Calcium ion (mmol/L)
25(OH)D normal (n=20) 1.09 (0.02) 1.18 (0.04) +8 <0.001
25(OH)D deficient (n=16) 1.08 (0.03) 1.18 (0.04) +9 <0.001
p Value (independent t-test) 0.88 0.42
Control group
25(OH)D (nmol/L)
25(OH)D normal (n=20) 74.6 (15.7) 81.7 (16.2) +10 <0.001
25(OH)D deficient (n=16) 37.5 (6.1) 41.9 (11.7) +12 0.34
p Value (independent t-test) <0.001 0.54
PTH (pg/mL)
25(OH)D normal (n=20) 57.2 (21.5) 60.6 (23.3) +6 0.19
25(OH)D deficient (n=16) 70.0 (24.2) 79.1 (35.7) +13 0.14
p Value (independent t-test) 0.07 0.69
Calcium ion (mmol/L)
25(OH)D normal (n=20) 1.10 (0.04) 1.29 (0.09) +18 <0.001
25(OH)D deficient (n=16) 1.09 (0.03) 1.26 (0.07) +16 <0.001
p Value (independent t-test) 0.29 0.54

Since there were no data about the intensity of UVB
from sun exposure in tropical countries, especially
in Indonesia, the first stage of this study aimed to
obtain the MED/hour value in our randomly selected
institutionalised care units, so as to determine the
time and duration of exposure the subjects might
need. This study encountered the highest intensity
of UVB from sun exposure about 1 hour before
and after midday. The exposure duration needed to
increase 25(OH)D concentration was longer when
subjects were exposed before 11 am and after 1 pm.
The lifestyle of most of the subjects in this study
was healthy with regard to vitamin D status. They
were not bed-ridden, undertook outdoor activities,
and rarely used sunscreen, thus allowing enough
sun exposure. Given that sun exposure is the most
important source, vitamin D status is expected
to relate to geographic location, being better in
residents close to the equator compared to those at
other latitudes. Vitamin D deficiency is thought to be
rare in the Indonesian population as the country is
exposed to sunlight all year long. However, our study
showed that the incidence of vitamin D deficiency
in elderly women was high (35%). In other studies
of elderly housebound people and nursing home
residents, one quarter and one half respectively
were vitamin D deficient.10,32 Environmental factors
such as the frequency of outdoor activity, low levels
of sun exposure, and low dietary intake are likely
contributing factors to the high prevalence of vitamin
D deficiency. The definition of vitamin D deficiency
may also affect estimation of its prevalence. However,
our study was not designed to explore the risk factors

130 Asian Journal of Gerontology & Geriatrics Vol 2 No 3 December 2007


of vitamin D deficiency. Instead, our aim was to
measure the difference of 25(OH)D and PTH levels
between exposed and non-exposed groups, before
and after sun enxposure.
Data have consistently shown that in the healthy
elderly people, 25(OH)D concentration is a function
of sun exposure. Cross-sectional and longitudinal
studies in white populations living in North Europe
and North America exhibit a marked seasonal
variation in serum 25(OH)D concentration, being
lowest during winter months, and highest in late
summer, consistent with the role of sun exposure
on 25 (OH)D concentrations.8,12,33 However, there
are certain other factors which also influence sun
exposure.34-36
Two demographic factors known to contribute to
sun exposure are age and skin pigmentation. Ageing
significantly affected the capacity of human skin to
produce vitamin D.19 Ageing decreases the amount
of 7-dehydrocholesterol produced in the skin, by as
much as 75% by the age of 70 years. Moreover, the
increase in 25(OH)D concentrations is also lower in
people who have greater amounts of melanin. The
exposure of Caucasian subjects (type-2 and -3 skins)
with 1 MED artificial UV irradiation greatly increased
25(OH)D concentrations by up to 60 fold within 24
to 48 hours of exposure, whereas this dosage did
not significantly change 25(OH)D concentrations in
Black (type 5-6 skin) subjects.22 From the perspective
of vitamin D synthesis, our study showed that
skin photosynthesis and hydroxylation in the liver
performed well in Indonesian elderly women with
type-4 skin colour, which was expressed by significant
increases of 25(OH)D concentration after 6 weeks of
sun exposure.
In the deficient group, PTH concentration
decreased slightly (1.4%) after 6 weeks of sun
exposure. This might have been due to better calcium
absorption after sun exposure (serum calcium levels
increased from 1.08 to 1.18 mmol/L) or the result of
calcium supplementation. In the deficient unexposed
group, PTH concentration increased after 6 weeks
(70 to 79 pg/mL), although serum calcium levels
increased from 1.09 to 1.26 mmol/L. From which it
may be assumed that the increase of serum calcium
levels was due to bone resorption through heightened
secondary hyperparathyroidism. Presumably, the low
25(OH)D concentration in this group was insufficient
Asian Journal of Gerontology & Geriatrics Vol 2 No 3 December 2007 131
Sun exposure on vitamin D3 and parathyroid level
for the formation of enough 1.25(OH)2D3 needed to
increase intestinal calcium absorption.
Other studies which used artificial UVB and
vitamin D supplementation found greater decreases
in PTH concentration.14,23 However, there are some
important differences between the study by Chel
et al23 and ours. Thus, all their subjects had severe
vitamin D deficiency (25(OH)D of <20 nmol/L) and
less skin pigmentation (type-2 and -3 skin). They also
used artificial UVB exposure from a reliably stable and
intense source.23 Both studies encountered the same
phenomenon, namely the lower the pre-exposure
25(OH)D concentration, the greater the increase of
25(OH)D concentration post-exposure.
Pfeifer et al14 compared elderly women given
1200 mg/day calcium and 800 IU/day vitamin
D supplementation for 8 weeks with those who
were given 1200 mg/day calcium supplementation
alone. They found that 25(OH)D increased 72%
and PTH decreased 18% in calcium and vitamin
D supplementation group. As in our study, they
found that the 25(OH)D concentration increased
significantly more in the deficient group (77% vs
72%).14 However, the PTH concentration decreased
less in our study than that in theirs (1.4% vs 18%).
Besides, the shorter duration of intervention (6
weeks of sun exposure in our study vs 8 weeks
of supplementation in theirs), as well as other
differences in the two populations (kidney and
parathyroid gland function, race and ethnicity) may
explain the contrasting PTH level responses.
The increase of 25(OH)D concentration after
sun exposure indicated that our subjects achieved
good vitamin D synthesis in skin, although they
were elderly with type-4 skins. Further vitamin D
synthesis in the liver was also good. Regrettably, the
increase of 25(OH)D concentration was not followed
by decreases in PTH concentration.
A limitation of our study was that the UV meter
measures UVB as well as UVA. In the early morning
more UVA gets through the stratosphere than UVB,
and thus the total UVB we measured might have
been a mix of both types.
In conclusion, vitamin D deficiency was found in
35% of Indonesian elderly women in institutionalised
care. Receipt of UVB from sun exposure for 25
 Setiati et al
minutes, 3 times a week, for 6 weeks improved the
vitamin D status, but not the PTH levels. It may take
more than 6 weeks of sun exposure to decrease PTH
levels. The optimal exposure time is 1 hour before
and after midday. Further studies with longer periods
of observation are needed to compare the effect of
sun exposure and vitamin D supplementation on
25(OH)D concentration, PTH levels, muscle strength,
and bone mass density. Further investigations are also
needed to explore into the timing and duration of
sun exposure in relation to 25(OH)D concentration,
in the context of different geographical locations,
climatic conditions, and seasons.
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